Provider Demographics
NPI:1447932280
Name:VIP IV & MEDICAL SPA, LLC
Entity type:Organization
Organization Name:VIP IV & MEDICAL SPA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:480-404-4896
Mailing Address - Street 1:1747 LOS LAGOS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6625
Mailing Address - Country:US
Mailing Address - Phone:480-404-4896
Mailing Address - Fax:480-400-1063
Practice Address - Street 1:1690 MCCULLOCH BLVD N STE 102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6560
Practice Address - Country:US
Practice Address - Phone:480-404-4896
Practice Address - Fax:480-400-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty